Should asymptomatic sinusitis found on computed tomography (CT) be treated?

Management of Asymptomatic Sinusitis Found on CT

Asymptomatic sinusitis incidentally found on CT scan should not be treated as it represents a normal variant rather than pathology requiring intervention. 1

Evidence-Based Rationale

Normal Findings vs. Pathology

• CT scans frequently show sinus abnormalities in completely healthy individuals:
  • 87% of young adults recovering from a cold show significant maxillary sinus abnormalities 1
  • 68% of symptomatic children with upper respiratory infections and 42% of healthy children have significant sinus abnormalities on imaging 1
  • 3-40% of asymptomatic adults have abnormalities on sinus CT scans 1, 2
  • In infants who had a cold in the 2 weeks before a head CT, 97% showed sinus abnormalities 1

Diagnostic Limitations

• The American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) explicitly states that imaging is unnecessary for patients with a clinical diagnosis of acute rhinosinusitis 1
• CT findings should always be interpreted in conjunction with clinical and endoscopic findings 2
• Multiple studies demonstrate poor correlation between CT findings and patient symptoms 3, 4

Clinical Decision Algorithm

1. Assess for symptoms:

   • If patient has NO symptoms (nasal congestion, facial pain/pressure, purulent discharge, decreased smell):
     • Do not treat - findings represent normal variant

2. Consider endoscopic evaluation:

   • The absence of mucopurulence on endoscopy is highly specific (100%) for excluding true sinusitis 5
   • If endoscopy shows no mucopurulence despite CT findings:
     • Do not treat - CT findings likely represent incidental abnormality

3. Evaluate for complications or concerning features:

   • If there are signs of orbital involvement, intracranial extension, or bone erosion:
     • Refer to specialist for further evaluation
   • If no complications are present:
     • Do not treat - asymptomatic findings do not require intervention

Important Caveats

• CT scans have high sensitivity but low specificity for sinusitis, leading to potential overdiagnosis 6
• Radiographic abnormalities alone are insufficient for diagnosis of sinusitis 1
• Treating based on imaging findings without clinical correlation may lead to unnecessary antibiotic use 5
• The European Position Paper on Rhinosinusitis (EPOS) guidelines emphasize that imaging should be interpreted in conjunction with clinical findings 1

Special Considerations

• In immunocompromised patients, closer monitoring may be warranted even with asymptomatic findings
• If CT was performed for headache evaluation, consider alternative diagnoses as paradoxically, headache and facial pain occur more frequently in patients with normal sinus CT scans 5

By following this evidence-based approach, unnecessary antibiotic use can be avoided while ensuring appropriate management of truly pathologic conditions.